Stephen F. Brockmeier

Outcomes After Arthroscopic Repair of Type-II SLAP Lesions

BACKGROUNDnTo our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation.nnnMETHODSnForty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and LInsalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded.nnnRESULTSnAt an average of 2.7 years, the median ASES and LInsalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or LInsalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness.nnnCONCLUSIONSnOur findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports.

Arthroscopic Intratendinous Repair of the Delaminated Partial-Thickness Rotator Cuff Tear in Overhead Athletes

A distinct type of partial-thickness rotator cuff tear has been observed in overhead athletes, characterized by partial failure of the undersurface of the posterior supraspinatus and anterior infraspinatus tendons with intratendinous delamination. We present a technique of percutaneous intratendinous repair using nonabsorbable mattress sutures designed for the management of articular-side delaminated partial-thickness tears. After tear evaluation and preparation, the torn rotator cuff undersurface is held in a reduced position with a grasper through an anterolateral rotator interval portal while viewing intra-articularly. Two spinal needles are then placed percutaneously through the full thickness of the torn and intact rotator cuff. A polydioxanone suture is passed through each needle, retrieved out the anterior portal, and used to shuttle a single nonabsorbable No. 2 suture through the tissue, creating a mattress suture. Multiple mattress sutures can be placed as dictated by tear size and morphology, with suture retrieval and knot securing then proceeding in the subacromial space. We have adopted this approach with the goals of anatomically re-establishing the rotator cuff insertion and sealing the area of intratendinous delamination while preventing significant alteration to the anatomy of the rotator cuff insertion, which could lead to motion deficits, internal impingement, and potential tear recurrence.

Etiology, Diagnosis, and Management of Failed SLAP Repair

In general, favorable outcomes have been achieved with arthroscopic repair of superior labral anterior-posterior (SLAP) tears. However, some patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment to alleviate their symptoms. The cause of persistent pain or recurrent symptoms after repair is likely multifactorial; therefore, careful preoperative workup is required to elucidate the cause of pain. Review of the details of previous surgical procedures is crucial because certain fixation methods are prone to failure or can cause additional injury. Failed SLAP repair can be managed with nonsurgical or surgical options. Nonsurgical modalities include physical therapy and strengthening programs, anti-inflammatory agents, and activity modification. Surgical options include revision SLAP repair and biceps tenotomy or tenodesis with or without revision SLAP repair. Outcomes after surgical management of failed SLAP repair are inferior to those of primary repair. Select patients may be better served by primary biceps tenodesis rather than SLAP repair.

Accelerated return to sport after osteochondral autograft plug transfer

Background: Previous studies have reported varying return-to-sport protocols after knee cartilage restoration procedures. Purpose: To (1) evaluate the time for return to sport in athletes with an isolated chondral injury who underwent an accelerated return-to-sport protocol after osteochondral autograft plug transfer (OAT) and (2) evaluate clinical outcomes to assess for any consequences from the accelerated return to sport. Study Design: Case series; Level of evidence, 4. Methods: An institutional cohort of 152 OAT procedures was reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent a physician-directed accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. Clinical outcomes were assessed using International Knee Documentation Committee (IKDC) and Tegner scores as well as assessment of level of participation on return to sport. Results: Return-to-sport data were available for all 20 athletes; 13 of 20 athletes (65%) were available for clinical evaluation at a mean 4.4-year follow-up. The mean time for return to sport for all 20 athletes was 82.9 ± 25 days (range, 38-134 days). All athletes were able to return to sport at their previous level and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The mean postoperative IKDC score was 84.5 ± 9.5. The mean Tegner score prior to injury was 8.9 ± 1.7; it was 7.7 ± 1.9 at final follow-up. Conclusion: Competitive athletes with traumatic chondral defects treated with OAT managed using this protocol had reduced time to preinjury activity levels compared with what is currently reported, with excellent clinical outcomes and no serious long-term sequelae.

Clinical Outcomes and Structural Healing After Arthroscopic Rotator Cuff Repair Reinforced With A Novel Absorbable Biologic Scaffold: A Prospective, Multicenter Trial

Objectives: Arthroscopic rotator cuff repair has been demonstrated to provide reliable clinical outcomes, but the rate of retear remains high (11% to 94%). Retears are associated with poorer outcomes and the majority of retears have been shown to occur within 6 months after surgical repair. Improving the mechanical and/or biological environment during index repair is a common strategy utilized to reduce retear rate. Biofiber© is a bi-layer, absorbable reinforced poly (4)-hydroxybutyrate scaffold that can be used to reinforce rotator cuff repair. Rotator cuff repairs augmented with Biofiber appear to have improved biomechanical properties as compared to standard repair constructs in cadaveric study. Therefore, BioFiber augmented rotator cuff repair may be a viable consideration for patients with larger tears, poorer tissue quality, or in revision repairs. The purpose of this prospective multi-center clinical trial is to evaluate the clinical outcomes and rates of successful healing by ultrasound evaluation in patients undergoing augmented arthroscopic rotator cuff repair using a BioFiber scaffold. Methods: A cohort of 50 patients were prospectively enrolled from three study sites in the US (2 sites) and France (1 site). Patients with an imaging demonstrated and arthroscopically confirmed full-thickness rotator cuff tear who underwent arthroscopic rotator cuff repair augmented with a BioFiber scaffold were included in the study. All patients were evaluated clinically at baseline prior to surgery, and subsequently at 6 months and 1 year post-operatively using functional outcomes evaluation (Constant Score and WORC Index), ROM, and strength testing. Ultrasound evaluation at 6 months and 1 year was also carried out to assess repair integrity. Results: The average patient age of the cohort was 61 ± 9 years with an average BMI of 28.4. There were 27 female (54%) and 23 male (46%) patients; 10% of those enrolled were workers compensation patients, 12% were undergoing revision rotator cuff repair. The average AP tear length was 25.2mm ± 1.8mm with an average retraction of 17.1mm ± 1.2mm from the greater tuberosity. Arthroscopic repairs were achieved in all 50 patients using either double-row (78%) or single-row (22%) constructs. The total surgical time for the procedure averaged 77 minutes, with a mean time required for placement of the Biofiber scaffold of 17 minutes. At 6 months post-operatively, the mean adjusted Constant Score was 94.0 (baseline 61.0) and the mean WORC Index was 82.1 (baseline 37.5). Ultrasound evaluation demonstrated intact repairs in 96% of the evaluated patients at the 6 month time point, with no additional evidence of repair failure at 1 year. Conclusion: This interim analysis suggests that reinforcement of rotator cuff repairs with Biofiber may result in a mechanically superior repair leading to a high rate of tendon healing. Tear size and quality of repair have been the best predictors for tendon healing in rotator cuff surgery, with recent studies demonstrating improved Constant scores when tendon healing is seen on ultrasound. This cohort had 96% rate of repair integrity on ultrasound evaluation. Furthermore, functional outcome scores after Biofiber-augmented repair were equal to or better than those recently reported for similar populations. Given this data, arthroscopic rotator cuff repair using a BioFiber augmented repair may provide a promising option in the treatment of patients with full-thickness rotator cuff tears.

Total Shoulder Arthroplasty in the Athlete and Active Individual

Shoulder arthroplasty is becoming more commonly performed in the United States. As it increases, the population also becomes younger, and their demands are different from the older population. Earlier studies have suggested that although young patients have functional outcomes similar to older patients, their satisfaction scores were not as high. Recent literature has demonstrated that young or active individuals with a total shoulder arthroplasty (TSA) have good return rates to sports. Hemiarthroplasty and reverse shoulder arthroplasty, when compared with TSA, have lower but also reasonable return rates to sports.

Shoulder Rotator Cuff Pathology: Common Problems and Solutions

Rotator cuff repair is an increasingly common orthopedic procedure. As with any surgical procedure, the complications can be potentially devastating when they do happen to occur. This review attempts to summarize the most frequently encountered complications, including retear, failure to heal, stiffness, missed concomitant pathology, and infection. Also included are several cases that outline the diagnosis and management of these complications.

Mri Arthroscopy Correlations: Introduction

N is credited with the dictum that “a picture is worth a thousand words.” Imagine then what many pictures, analyzed in concert, are worth. The senior guest editor has championed the concept of correlating magnetic resonance imaging and arthroscopy from the beginning of his career. The genesis of this included regular visits to the dark halls of radiology, arthroscopic pictures in hand, to discuss findings with the musculoskeletal radiologist who interpreted the original images. Over the years, this blossomed into symposia (the original one was “standing room only” and risked intervention by the fire marshal), instructional course lectures, stand-alone conferences, articles, chapters, and even books (the most recent one edited by the junior guest editor for this issue of SMAR). We invited arthroscopic experts to enlist the help of musculoskeletal radiologists with whom they work with on a daily basis, to share images that correlate magnetic resonance imaging and arthroscopic findings using a case-based format. The result is a comprehensive compendium of anatomically based findings. We still meet with our musculoskeletal radiologists in a popular conference on a regular basis. It is a great way to share findings and continue our pursuit of life-long learning. We would like to thank the Editor of this series, Dr Greg Fanelli, and the wonderful folks at Wolters Kluwer, especially Naima Stone, for inviting us to put this edition together and helping us along the way. Enjoy!

A Comparison of Cervical Spine Motion After Immobilization With a Traditional Spine Board and Full-Body Vacuum-Mattress Splint:

Background: The National Athletic Trainers’ Association (NATA) advocates for cervical spine immobilization on a rigid board or vacuum splint and for removal of athletic equipment before transfer to an emergency medical facility. Purpose: To (1) compare triplanar cervical spine motion using motion capture between a traditional rigid spine board and a full-body vacuum splint in equipped and unequipped athletes, (2) assess cervical spine motion during the removal of a football helmet and shoulder pads, and (3) evaluate the effect of body mass on cervical spine motion. Study Design: Controlled laboratory study. Methods: Twenty healthy male participants volunteered for this study to examine the influence of immobilization type and presence of equipment on triplanar angular cervical spine motion. Three-dimensional cervical spine kinematics was measured using an electromagnetic motion analysis system. Independent variables included testing condition (static lift and hold, 30° tilt, transfer, equipment removal), immobilization type (rigid, vacuum-mattress), and equipment (on, off). Peak sagittal-, frontal-, and transverse-plane angular motions were the primary outcome measures of interest. Results: Subjective ratings of comfort and security did not differ between immobilization types (P > .05). Motion between the rigid board and vacuum splint did not differ by more than 2° under any testing condition, either with or without equipment. In removing equipment, the mean peak motion ranged from 12.5° to 14.0° for the rigid spine board and from 11.4° to 15.4° for the vacuum-mattress splint, and more transverse-plane motion occurred when using the vacuum-mattress splint compared with the rigid spine board (mean difference, 0.14 deg/s [95% CI, 0.05-0.23 deg/s]; P = .002). In patients weighing more than 250 lb, the rigid board provided less motion in the frontal plane (P = .027) and sagittal plane (P = .030) during the tilt condition and transfer condition, respectively. Conclusion: The current study confirms similar motion in the vacuum-mattress splint compared with the rigid backboard in varying sized equipped or nonequipped athletes. Cervical spine motion occurs when removing a football helmet and shoulder pads, at an unknown risk to the injured athlete. In athletes who weighed more than 250 lb, immobilization with the rigid board helped to reduce cervical spine motion. Clinical Relevance: Athletic trainers and team physicians should consider immobilization of athletes who weigh more than 250 lb with a rigid board.

ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?:

Background: Anatomic femoral tunnel placement for single-bundle anterior cruciate ligament (ACL) reconstruction is now well accepted. The ideal location for the tibial tunnel has not been studied extensively, although some biomechanical and clinical studies suggest that placement of the tibial tunnel in the anterior part of the ACL tibial attachment site may be desirable. However, the concern for intercondylar roof impingement has tempered enthusiasm for anterior tibial tunnel placement. Purpose: To compare the potential for intercondylar roof impingement of ACL grafts with anteriorly positioned tibial tunnels after either transtibial (TT) or independent femoral (IF) tunnel drilling. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaver knees were randomized to either a TT or IF drilling technique. Tibial guide pins were drilled in the anterior third of the native ACL tibial attachment site after debridement. All efforts were made to drill the femoral tunnel anatomically in the center of the attachment site, and the surrogate ACL graft was visualized using 3-dimensional computed tomography. Reformatting was used to evaluate for roof impingement. Tunnel dimensions, knee flexion angles, and intra-articular sagittal graft angles were also measured. The Impingement Review Index (IRI) was used to evaluate for graft impingement. Results: Two grafts (2/6, 33.3%) in the TT group impinged upon the intercondylar roof and demonstrated angular deformity (IRI type 1). No grafts in the IF group impinged, although 2 of 6 (66.7%) IF grafts touched the roof without deformation (IRI type 2). The presence or absence of impingement was not statistically significant. The mean sagittal tibial tunnel guide pin position prior to drilling was 27.6% of the sagittal diameter of the tibia (range, 22%-33.9%). However, computed tomography performed postdrilling detected substantial posterior enlargement in 2 TT specimens. A significant difference in the sagittal graft angle was noted between the 2 groups. TT grafts were more vertical, leading to angular convergence with the roof, whereas IF grafts were more horizontal and universally diverged from the roof. Conclusion: The IF technique had no specimens with roof impingement despite an anterior tibial tunnel position, likely due to a more horizontal graft trajectory and anatomic placement of the ACL femoral tunnel. Roof impingement remains a concern after TT ACL reconstruction in the setting of anterior tibial tunnel placement, although statistical significance was not found. Future clinical studies are planned to develop better recommendations for ACL tibial tunnel placement. Clinical Relevance: Graft impingement due to excessively anterior tibial tunnel placement using a TT drilling technique has been previously demonstrated; however, this may not be a concern when using an IF tunnel drilling technique. There may also be biomechanical advantages to a more anterior tibial tunnel in IF tunnel ACL reconstruction.